Provider Demographics
NPI:1346082724
Name:KAMBO, ENDRI
Entity type:Individual
Prefix:
First Name:ENDRI
Middle Name:
Last Name:KAMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 15TH ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-3343
Mailing Address - Country:US
Mailing Address - Phone:734-596-9804
Mailing Address - Fax:
Practice Address - Street 1:6760 ALLEN RD STE 101
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2062
Practice Address - Country:US
Practice Address - Phone:313-928-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901602196122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist